Sidney Barnett · Prevention of Future Deaths report

On 14th January 2015 I commenced an investigation into the death of Sidney Barnett dob 7th February 1924. The investigation concluded on the 12th June 2015 and the conclusion was one of Natural Causes. The medical cause of death was 1a Bronchopneumonia 1b Dementia 11. Coronary Artery Atheroma and Type 2 Diabetes Mellitus.

The deceased was resident at a Care Home for the elderly. He was gradually declining in health. On the 21st December 2014 he was in his room and was seen by his relatives to be without socks, he had the remnants of his dinner all over the front of his clothes, he was unshaven and he was struggling to eat a bowl of custard, alone and unattended.
The following day his relatives again visited him at the home and he was seen to be wearing only a T shirt and was sitting in his chair close to a window which was open, even though it was late December and the weather was cold. Later that evening he was seen by a District Nurse who was there to administer his insulin, and she, through the out-of-hours doctor, immediately admitted him to hospital where he died from pneumonia on the 3rd January 2015.

1. Whilst at Berrycroft, the level and quality of observation of the client appears to have been inadequate.
2. There was an insufficiency of care shown to the deceased in terms of his general welfare (whether he was warm enough, whether he was washed and shaved, whether he was able to take his meals safely, whether his clothing was adequate and clean etc.).
3. The 'cleaner' at the care Home “opens the windows, whatever..” There seemed to be no clear rule in place as regards the appropriateness of the windows being open.
[ Items 1to 3 should be addressed by Berrycroft]

4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated.
5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened.
[Items 4 and 5 to be answered by S.M.B.C.]